Basic Information
| Provider Information | |||||||||
| NPI: | 1063810893 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH EAST GUIDANCE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 CONNER ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482152407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133081400 | ||||||||
| FaxNumber: | 3133081600 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 CONNER ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482152407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133081400 | ||||||||
| FaxNumber: | 3133081600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2014 | ||||||||
| LastUpdateDate: | 12/10/2014 | ||||||||
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| AuthorizedOfficialLastName: | REID | ||||||||
| AuthorizedOfficialFirstName: | ALTON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | QUALIFIED MENTAL HEALTH PROFESSIONA | ||||||||
| AuthorizedOfficialTelephone: | 3133081400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 1922037134 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 251B00000X | 1922037134 | MI | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 1923037134 | 05 | MI | MEDICAID |